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Affirmative Action Survey

Government agencies require periodic reports on the sex, ethnicity, disability and veteran status of employees. This data is for analysis and affirmative action purposes only. Submission of information is voluntary. If you do not wish to complete the questionnaire, please indicate at which institution you are employed, print your name and social security number, and send the survey electronically to Maggie Hyndman or send it by campus mail to her at the Human Resource Office, USNH – Dunlap Center, Durham, NH 03824.

Download in Word Format

Institution:

Last Name: First Name: Initial:

Social Security Number:

Please designate appropriate answers:

Gender: Female Male

Date of Birth (Month/Day/Year): / /

Ethnic Background: (check one)

Hispanic or Latino – A person of Cuba, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.
Non-Hispanic or Latino

Race: (check one)

American Indian or Alaskan Native – A person having origins in any of the original peoples of North and South America, and who maintains tribal affiliation or community attachment.
Asian – A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand and Vietnam.
Black or African American – A person having origins in any of the black racial groups of Africa.
Native Hawaiian or Other Pacific Islander – A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands.
White – A person having origins in any of the original peoples of Europe, North Africa or the Middle East.
Two or More Races – The race I most closely identify with is:___________

Veteran Status: (check all that apply)

Veteran Era Veteran Vietnam Era Veteran means a person who:

1. Served on active duty for a period of more than 180 days, and was discharged or released there from with other than a dishonorable discharge, if any part of such active duty occurred:

a. in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or

b. between August 5, 1964 and May 7, 1975, in all other cases: or

2. Was discharged or released from active duty for a service-connected disability if any part of such active duty was performed:

a. in the Republic of Vietnam between February 28, 1961 and May 7, 1975; or

b. between August 5, 1964 and May 7, 1975, in all other cases.

War/Campaign/Expedition Veteran War/Campaign/Expedition Veteran means:

A veteran who served on active duty during a war or in a campaign or expedition for which a campaign badge has been authorized.

Special Disabled Veteran Special Disabled Veteran means:

1. A veteran who is entitled to compensation (or who, but for receipt of military retired pay, would be entitled to compensation) under laws administered by the Department of Veteran’s Affairs for a disability:

rated at 30 percent or more, or

rated at 10 to 20 percent, in the case of a veteran who has been determined under Section 3106 of Title 38, USC, to have a serious employment handicap; or

2. A person who was discharged or released from active duty because of a service-connected disability.

Recently Separated Veteran:

Any veteran who served on active duty in the U.S. Military (ground, naval or air service) during the one year period beginning on the date of such veteran’s discharge or release from duty.